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The thought began to germinate during the past Christmas holidays. It may have been the religious connotation, the gathering of family, or just the general “peace on earth” sense of the season that created a contemplative mood. Slowly, what had been an abstract concept about a military action in Iraq began to assume the realities associated with war. The possibility of war clearly has implications for everyone. However, the mortality and injury inflicted upon healthy and usually young human beings has particular significance for physicians, who devote their careers to prolonging life and abolishing disability. It therefore seemed entirely important and appropriate to devote an Editor’s Page to war and its implications for physicians.

This manuscript is being written in mid-January while the prospect for war is still uncertain. However, we live in an age where armed conflict and violence is rampant. In terms of the U.S., we have just completed a war in Afghanistan and continue to house troops in that country. United Nations inspectors are searching Iraq for weapons of mass destruction while American troops gather on its borders. A major confrontation is underway with North Korea over the prospect of a nuclear arms program being developed in that country. In addition, terrorist attacks have and continue to occur in many areas of the world. Clearly, the issue of war somewhere in the world is likely to remain a significant possibility for many years to come.

It should be stated at the outset that I am not a conscientious objector. I believe that war is justifiable for self-defense, and can even sympathize with those who, following the events of September 11, defend the justifiability of pre-emptive action to prevent mass destruction. However, in absolute terms I am vigorously and unalterably opposed to war and feel that it should be undertaken only as the very last resort when confronted with intolerable consequences. This should not be regarded as a very profound pronouncement; who in his or her right mind can be in favor of war? Surely those who support war must be in the same league as those against motherhood and apple pie. No, I believe that nearly everyone shares the inherent abhorrence of killing. Rather, the problem seems to me to be our losing sight of the reality of war, and of death on both sides, when we consider whether the last resort has been reached and if a consequence of inaction would be sufficiently dire.

As a general statement, war is totally irrational. It seems inconceivable that sane individuals could not reach some acceptable compromise to any dispute other than trying to kill each other. Although the absurdity of war should be apparent to everyone, it is particularly germane for physicians. In fact, war is the antithesis of healing, and it makes a mockery of everything to which we devote our professional lives. I recently spent a large portion of three days attending to an acutely ill octogenarian with advanced ischemic cardiomyopathy and refractory heart failure. The goal was to extend this very restricted life for perhaps a year or two. Even were such therapy completely successful, it would pale compared with the benefit that could be achieved by eliminating the death and disability produced by a single bomb appropriately deployed in battle. In some sense, it could be argued that my overall effect on society, and that of physicians in general, would be greater if our energy were devoted to achieving peace rather than treating coronary heart disease and congestive heart failure.

The role of biomedical scientists has become even more complicated in contemporary conflict. We live in an age of potential bioterrorism and must deal with the possibility of biological and chemical weapons such as anthrax, smallpox, and mustard gas, among others. Physicians constitute the cavalry that will be called into combat in such an attack. In fact, it is only the knowledge, expertise, and perhaps innovation of biomedical scientists that make it possible for such biologicals to be converted to weapons. This use of knowledge to kill rather than cure surely represents the ultimate perversion of the profession. Given the existing world conditions, physicians find themselves in the extraordinary position of being enlisted to battle disease that is inflicted not by nature but by our fellow man. It is vaguely disorienting, to say the least, to watch news programs that simultaneously interview military officers and physicians regarding their plans for possible hostile military and biological attacks.

A good deal of my thinking on this issue had been organized and outlined when I encountered an exchange that was extremely germane to the topic. Specifically, an internet website established by the World Association of Medical Editors (WAME), an international organization of editors of medical journals, began to debate the appropriateness of addressing the issue of war in medical journals. Some editors felt that journals should be devoted to science and the healing arts and should be insulated from contemporary events in society. In particular, they felt strongly that biomedical science should be divorced from politics. Others felt that war was an important aspect of health and was a perfectly appropriate topic for medical journals. A few pointed out that the presentation of war-related content in medical journals often has political colorations and implications. Clearly, no consensus existed. For my part, despite its obvious impact on human health, I think politics should generally be directed to publications other than medical journals. The clear exception, of course, would be the politics involving health care delivery itself. However, as evidenced by this piece, I believe war is a perfectly appropriate subject for medical journals, since the goal of medicine is to prolong life and reduce suffering and war shortens life and induces suffering. Moreover, the failure to address the issue of war in medical journals suggests an acquiescence of the medical profession to an irrational activity.

Granted that war is antithetical to everything the medical profession stands for, what action should be taken? It is my impression that almost any action would represent a marked increase in activity compared with the current state of affairs. It appears that most physicians share my original detached sense of abstractness as they put down the morning paper to leave for the hospital or office. I hear very few comments in the wards, labs, or cafeteria about potential war. We need more conversation and debate among ourselves regarding the consequences of armed conflict and the possible alternatives. We, who strive so hard to prolong the survival of even individuals who have a significantly reduced quality of life, should have the loudest voice in cautioning against killing. We should demand that every possible alternative be exhausted before a single shot is fired and should require, as a condition for the use of force, that failure to engage in battle would lead to intolerable consequences. We should weed out any colleague who exploits medical/biological knowledge to create weapons while we simultaneously prepare ourselves to protect society from the consequences of any such action. It is only by taking such a proactive position and by engaging parties inside and outside the profession that we can fully discharge our responsibility to maximize the health of society. It is only by taking such action that we can prepare ourselves to provide the medical care necessary for a successful war effort, should the irrational become unavoidable.

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